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ATLAS OF Ultrasound-Guided Musculoskeletal Injections

ATLAS OF Ultrasound-Guided Musculoskeletal Injections · ATLAS OF Ultrasound-Guided Musculoskeletal Injections Gerard A. Malanga, MD Clinical Professor Department of Physical Medicine

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ATLAS OF Ultrasound-Guided Musculoskeletal Injections

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NOTICEMedicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the pos-sibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibil-ity for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with the new or infrequently used drugs.

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ATLAS OF Ultrasound-Guided Musculoskeletal Injections

Gerard A. Malanga, MDClinical ProfessorDepartment of Physical Medicine and RehabilitationUMDNJ—New Jersey Medical SchoolNewark, New JerseyFounding PartnerNew Jersey Sports Medicine, LLCSummit, New Jersey

Kenneth R. Mautner, MDAssistant ProfessorDepartment of OrthopaedicsPhysical Medicine and RehabilitationEmory HealthcareAtlanta, Georgia

New York Chicago San Francisco Athens London Madrid

Mexico City Milan New Delhi Singapore Sydney Toronto

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Atlas of Ultrasound-Guided Musculoskeletal Injections

Copyright © 2014 by McGraw-Hill Education. All rights reserved. Printed in China. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a data base or retrieval system, without the prior written permission of the publisher.

1 2 3 4 5 6 7 8 9 0 CTP/CTP 19 18 17 16 15 14

ISBN 978-0-07-176967-9MHID 0-07-176967-6

This book was set in Times by Thomson Digital.The editors were Brian Belval and Christina M. Thomas.The production supervisor was Catherine Saggese.Project management was provided by Ritu Joon, Thomson Digital.The text designer was Janice Bielawa.The cover designer was Thomas De Pierro.China Translation & Printing Services, Ltd. was printer and binder.

Library of Congress Cataloging-in-Publication Data

Atlas of ultrasound-guided musculoskeletal injections / [edited by] Gerard Malanga, Kenneth R. Mautner. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-07-176967-9 (print book : alk. paper) ISBN-10: 0-07-176967-6 (print book : alk. paper) ISBN-13: 978-0-07-177204-4 (ebook) I. Malanga, Gerard A. II. Mautner, Kenneth R. [DNLM: 1. Musculoskeletal Diseases—ultrasonography—Atlases. 2. Injections—methods—Atlases. 3. Nerve Block—methods—Atlases. 4. Orthopedic Procedures—methods—Atlases. 5. Ultrasonography, Interventional—methods—Atlases. WE 17] RC925.7 616.7’07543—dc23 2013014104

McGraw-Hill Education books are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. To contact a representative, please visit the Contact Us pages at www.mhprofessional.com.

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CONTENTS

Contributors .......................................................................................................................................................................................... xi

Foreword .............................................................................................................................................................................................xvii

Preface ..................................................................................................................................................................................................xix

Acknowledgments .............................................................................................................................................................................xxi

SECTION I Introduction 1

1. Introduction to Interventional Ultrasound ...................................................................................................................................................2Christopher J. Visco, MD

2. Ultrasound Physics for Interventional Procedures ....................................................................................................................................6Matthew D. Maxwell, MD / Nicholas H. Weber, DO / Gary P. Chimes, MD, PhD

3. Preparation and Setup for Musculoskeletal Ultrasound-Guided Procedures................................................................................14Paul H. Lento, MD

4. The Rationale and Evidence for Performing Ultrasound-Guided Injections ..................................................................................18Gerard A. Malanga, MD / Matthew Axtman, DO / Kenneth R. Mautner, MD

SECTION II Shoulder 23

5. Glenohumeral Joint Injection ..........................................................................................................................................................................24Troy Henning, DO

6. Acromioclavicular Joint Injection ...................................................................................................................................................................28Evan Peck, MD

7. Sternoclavicular Joint Injection ......................................................................................................................................................................33Evan Peck, MD

8. Subacromial-Subdeltoid Bursa Injection .....................................................................................................................................................36Gregory R. Saboeiro, MD

9. Biceps Tendon Sheath Injection .....................................................................................................................................................................40Sean N. Martin, DO / Joshua G. Hackel, MD, FAAFP

10. Subcoracoid Bursa Injection ............................................................................................................................................................................44Joshua G. Hackel, MD, FAAFP

11. Suprascapular Nerve Injection ........................................................................................................................................................................47Johan Michaud, MD, FRCPC

SECTION III Elbow 51

12. Elbow Joint Injection ..........................................................................................................................................................................................52Jonathan S. Halperin, MD

13. Common Extensor Tendon Peritendinous Injection ..............................................................................................................................57Scott Jeffery Primack, DO, FAAPMR, FACOPMR

14. Common Extensor Tendon Percutaneous Tenotomy ............................................................................................................................61John M. McShane, MD

15. Common Flexor Tendon Peritendinous Injection....................................................................................................................................65Scott Jeffery Primack, DO, FAAPMR, FACOPMR

16. Common Flexor Tendon Percutaneous Tenotomy .................................................................................................................................69Bradley D. Fullerton, MD

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vi ■ Contents

17. Distal Biceps Tendon and Bicipitoradial Bursa Injection .......................................................................................................................73Mederic M. Hall, MD

18. Distal Biceps Tendon Percutaneous Tenotomy ........................................................................................................................................78Mederic M. Hall, MD

19. Procedures of the Distal Triceps Tendon: Tendon Sheath and Percutaneous Tenotomy ........................................................82Jose A. Ramirez-Del Toro, MD

20. Ulnar Collateral Ligament Percutaneous Tenotomy ...............................................................................................................................86Joshua G. Hackel, MD, FAAFP

21. Olecranon Bursa Aspiration and Injection ..................................................................................................................................................89R. Amadeus Mason, MD

22. Deep Branch of the Radial Nerve Injection .................................................................................................................................................93Sean W. Mulvaney, MD

23. Ulnar Nerve Injection ..........................................................................................................................................................................................98Evan Peck, MD / Brian J. Shiple, DO

24. Median Nerve at the Pronator Teres Injection .......................................................................................................................................102Victor Ibrahim, MD / Adam D. Weglein, DO, DABMA

SECTION IV Hand and Wrist 107

25. Radiocarpal Joint Injection ............................................................................................................................................................................108Darryl Eugene Barnes, MD

26. Ganglion Cyst in the Wrist Aspiration and Injection ............................................................................................................................112B. Elizabeth Delasobera, MD / Garry Wai Keung Ho, MD, CAQSM / Thomas M. Howard, MD, FACSM

27. Distal Radial Ulnar Joint Injection ...............................................................................................................................................................115Darryl Eugene Barnes, MD

28. Scapholunate Joint Injection ........................................................................................................................................................................119Joseph J. Ruane, DO / Paul A. Cook, MD / Jeffrey A. Strakowski, MD

29. Carpal-Metacarpal Joint Injection ...............................................................................................................................................................122John FitzGerald, MD

30. Scaphotrapeziotrapezoidal Joint Injection .............................................................................................................................................125Kevin B. Dunn, MD, MS

31. Interphalangeal Joints Injection ..................................................................................................................................................................128Mark-Friedrich Berthold Hurdle, MD

32. First Extensor Compartment Injection: Abductor Pollicis Longus and Extensor Pollicis Brevis ...........................................131Ricardo J. Vasquez-Duarte, MD / Jackson Cohen, MD

33. Second Dorsal Compartment of Wrist Injection ....................................................................................................................................135Ricardo J. Vasquez-Duarte, MD / Jackson Cohen, MD

34. Intersection Syndrome of the First and Second Dorsal Compartments Injection ....................................................................138Bradly S. Goodman, MD / Prasanth Nuthakki, MD / Matthew Thomas Smith, MD / Srinivas Mallempati, MD

35. Third Dorsal Compartment of the Wrist Injection ................................................................................................................................141Sean N. Martin, DO

36. Distal Intersection Syndrome Injection ....................................................................................................................................................144Bradly S. Goodman, MD / Matthew Thomas Smith, MD / Prasanth Nuthakki, MD / Srinivas Mallempati, MD

37. Fourth Dorsal Compartment of the Wrist Injection .............................................................................................................................148Sean N. Martin, DO

38. Fifth Dorsal Compartment of the Wrist Injection ..................................................................................................................................152Todd P. Stitik, MD / Kambiz Nooryani, MD / Prathap Jayaram, MD / Asal Sepassi, MD

39. Sixth Dorsal Compartment of the Wrist Injection .................................................................................................................................155Todd P. Stitik, MD / Asal Sepassi, MD / Prathap Jayaram, MD / Kambiz Nooryani, MD

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Contents ■ vii

40. Stenosing Tenosynovitis at the First Annular Pulley Injection .........................................................................................................158Jeffrey A. Strakowski, MD

41. Flexor Carpi Radialis Injection ......................................................................................................................................................................162Rebecca Ann Myers, MD / Jennifer K. Malcolm, DO / Mark Edward Lavallee, MD, CSCS, FACSM

42. Flexor Digitorum Superficialis and Profundus Tendon Sheath Injection .....................................................................................167Luis Baerga-Varela, MD

43. Carpal Tunnel Injection ...................................................................................................................................................................................171Jeffrey A. Strakowski, MD

44. Superficial Radial Nerve Injection ...............................................................................................................................................................176Paul D. Tortland, DO, FAOASM

SECTION V Pelvis 183

45. Sacroiliac Joint Injection .................................................................................................................................................................................184Mark-Friedrich Berthold Hurdle, MD

46. Hip Joint Injection .............................................................................................................................................................................................188Jerod A. Cottrill, DO

47. Hip Paralabral Cyst Aspiration and Injection ..........................................................................................................................................191Marko Bodor, MD / Sean Colio, MD

48. Pubic Symphysis Joint Injection ..................................................................................................................................................................195Ched Garten, MD

49. Piriformis Injection ...........................................................................................................................................................................................198Steve J. Wisniewski, MD / Jay Smith, MD

50. Obturator Internus Injection .........................................................................................................................................................................201Steve J. Wisniewski, MD / Jay Smith, MD

51. Ischial Bursa Peritendinous Injection .........................................................................................................................................................204Kimberly G. Harmon, MD

52. Hamstring Origin Percutaneous Needle Tenotomy .............................................................................................................................209Kimberly G. Harmon, MD

53. Greater Trochanteric Bursae Injection.......................................................................................................................................................213Marko Bodor, MD / John M. Lesher, MD, MPH

54. Gluteus Medius and Minimus Percutaneous Tenotomy ....................................................................................................................219Jon A. Jacobson, MD

55. Iliopsoas Bursa Peritendinous Injection ....................................................................................................................................................224Jon A. Jacobson, MD

56. Procedures of the Adductor Tendon: Tendon Sheath Injection and Percutaneous Tenotomy ..........................................228Henry A. Stiene, MD, FACSM

57. Quadriceps Hematoma Aspiration .............................................................................................................................................................233Robert Monaco, MD / Megan Groh Miller, MD

58. Sciatic Nerve Injection .....................................................................................................................................................................................236Joanne Borg Stein, MD

59. Femoral Nerve Injection .................................................................................................................................................................................239Danielle Aufiero, MD / Steven Sampson, DO

60. Obturator Nerve Injection ..............................................................................................................................................................................243Joanne Borg Stein, MD

61. Lateral Femoral Cutaneous Nerve Injection ............................................................................................................................................246Paul D. Tortland, DO, FAOASM

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viii ■ Contents

SECTION VI Knee 251

62. Intraarticular Injections of the Knee ...........................................................................................................................................................252John C. Cianca, MD

63. Gastrocnemius-Semimembranosus Bursa (Baker’s Cyst) Aspiration and Injection ..................................................................258Brandon J. Messerli, DO / Garrett S. Hyman, MD, MPH / R. Amadeus Mason, MD

64. Paramensical Cyst Aspiration and Injection ............................................................................................................................................263Jeffrey M. Payne, MD

65. Proximal Tibiofibular Joint Injection ..........................................................................................................................................................266Jeffrey M. Payne, MD

66. Distal Quadriceps Injection and Tenotomy .............................................................................................................................................269Ronald W. Hanson Jr, MD, CAQSM

67. Patellar Tendon Needle Tenotomy.............................................................................................................................................................272Joseph J. Albano, MD

68. Prepatellar Bursal Injection ...........................................................................................................................................................................277Joseph J. Albano, MD

69. Infrapatellar Bursa Injection ..........................................................................................................................................................................281Beth M. Weinman, DO / Kate E. Temme, MD / Megan L. Noon, MD / Anne Z. Hoch, DO

70. Distal Iliotibial Band: Peritendinous Injection and Percutaneous Tenotomy .............................................................................287Eugene Yousik Roh, MD / Michael Fredericson, MD

71. Popliteus Tendon: Tendon Sheath and Percutaneous Tenotomy ..................................................................................................292Brandee L. Waite, MD

72. Distal Biceps Femoris: Peritendinous Injection, Tenotomy, and Fenestration ...........................................................................296Robert Monaco, MD / Megan Groh Miller, MD

73. Procedures of the Distal Semimembranosus Tendon: Peritendinous and Percutaneous Tenotomy ...............................300Brandon J. Messerli, DO / Garrett S. Hyman, MD, MPH

74. Pes Anserine Bursa Injection .........................................................................................................................................................................303Jacob L. Sellon, MD / Jay Smith, MD

75. Tibial Collateral Ligament Bursa Injection ...............................................................................................................................................307Troy Henning, DO

76. Tibial Nerve Injection at Posterior Knee ...................................................................................................................................................310John L. Lin, MD

77. Common Peroneal Nerve Injection ............................................................................................................................................................316John L. Lin, MD

78. Saphenous Nerve Injection ...........................................................................................................................................................................320Joanne Borg Stein, MD

SECTION VII Foot and Ankle 325

79. Distal Tibiofibular Joint Injection ................................................................................................................................................................326Charles E. Garten II, MD

80. Tibiotalar Joint Injection .................................................................................................................................................................................329Kevin deWeber, MD, FAAFP, FACSM

81. Subtalar (Talocalcaneal) Joint Injection ....................................................................................................................................................333Kevin deWeber, MD, FAAFP, FACSM

82. Sinus Tarsi Injection .........................................................................................................................................................................................336Keith Hardy, MD

83. Talonavicular Joint Injection .........................................................................................................................................................................339Keith Hardy, MD

84. Tarsometatarsal (Lisfranc) Joint Injection ................................................................................................................................................343Arthur Jason De Luigi, DO, FAAPMR, DAPM

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Contents ■ ix

85. Calcaneocuboid Injection ..............................................................................................................................................................................347Arthur Jason De Luigi, DO, FAAPMR, DAPM

86. Metatarsophalangeal Joint Injection .........................................................................................................................................................351Eric Robert Helm, MD / Nicholas H. Weber, DO / Megan Helen Cortazzo, MD

87. Interphalangeal Joint Injection ....................................................................................................................................................................354Eric Robert Helm, MD / Nicholas H. Weber, DO / Megan Helen Cortazzo, MD

88. Metatarsosesamoid Joint Injection ............................................................................................................................................................357Nicholas H. Weber, DO / Eric Robert Helm, MD / Megan Helen Cortazzo, MD

89. Tibialis Anterior Tendon Sheath and Tibialis Anterior Bursa Injection ..........................................................................................360Nelson A. Hager, MS, MD / Alfred C. Gellhorn, MD

90. Tendon Sheath Injection and Percutaneous Tenotomy of the Distal Peroneal Brevis Tendon ...........................................364Nelson A. Hager, MS, MD

91. Achilles Paratenon Injection .........................................................................................................................................................................367Luis Baerga-Varela, MD

92. Achilles Tendon Injection and Tenotomy ................................................................................................................................................372Bradley D. Fullerton, MD

93. Retrocalcaneal Bursa Injection .....................................................................................................................................................................378Mandy Huggins, MD / Gerard A. Malanga, MD

94. Retro-Achilles Bursa Injection .......................................................................................................................................................................380Mandy Huggins, MD / Gerard A. Malanga, MD

95. Tibialis Posterior Injection and Tenotomy ...............................................................................................................................................382Christopher J. Visco, MD

96. Flexor Hallucis Longus Tendon Sheath Injection ..................................................................................................................................387Johan Michaud, MD, FRCPC

97. Plantar Fascia Perifascial Injection ..............................................................................................................................................................392John C. Hill, DO, FACSM, FAAFP / Matthew Leiszler, MD

98. Plantar Fascia Intrafascial Injection ............................................................................................................................................................397John C. Hill, DO, FACSM, FAAFP / Matthew Leiszler, MD

99. Tibial Nerve Injection at the Ankle ..............................................................................................................................................................402John C. Hill, DO, FACSM, FAAFP / Matthew Leiszler, MD / Jay E. Bowen, DO

100. Saphenous Nerve Injection at the Ankle ..................................................................................................................................................407Amy X. Yin, MD / Joanne Borg Stein, MD

101. Sural Nerve Injection ........................................................................................................................................................................................410Rahul Naren Desai, MD / Jevon Simerly

102. Morton’s Neuroma Injection .........................................................................................................................................................................413Michael Goldin, MD / Brian J. Shiple, DO

SECTION VIII Special Procedures 419

103. Lavage and Aspiration of Rotator Cuff Calcific Tendinosis ................................................................................................................420Gregory R. Saboeiro, MD

104. Intrasheath Percutaneous Release of the First Annular Digital Pulley for Trigger Digits .......................................................425Jose Manuel Rojo Manaute, MD, PhD / Guillermo Emilio Rodríguez-Maruri, MD / Alberto Capa-Grasa, MD, PhD

105. Ultra-Minimally Invasive Carpal Tunnel Release ....................................................................................................................................430Jose Manuel Rojo Manaute, MD, PhD / Alberto Capa-Grasa, MD, PhD / Guillermo Emilio Rodríguez-Maruri, MD / Jay Smith, MD / Javier Vaquero Martín, MD, PhD

106. Percutaneous Tenotomy of the Common Extensor Tendon ............................................................................................................438Darryl Eugene Barnes, MD

Index ................................................................................................................................................................................................... 443

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CONTRIBUTORS

Joseph J. Albano, MDPrivate Practice of Regenerative and Sports MedicineTeam Physician for US Speedskating, Real Salt Lake Soccer,

US Military CyclingWestminster CollegeSalt Lake City, Utah

Danielle Aufiero, MDClinical Assistant ProfessorDepartment of Physical Medicine and RehabilitationWestern University of Health SciencesPomona, California

Matthew Axtman, DOSports Medicine FellowDepartment of OrthopaedicsEmory UniversityAtlanta, Georgia

Luis Baerga-Varela, MDAssistant ProfessorDepartment of Physical Medicine, Rehabilitation and Sports MedicineUniversity of Puerto RicoSan Juan, Puerto Rico

Darryl Eugene Barnes, MDConsultantDepartment of OrthopedicsMayo Clinic Health SystemAustin, Minnesota

Marko Bodor, MDAssistant ProfessorDepartment of Neurological SurgeryUniversity of California San FranciscoSan Francisco, California

Jay E. Bowen, DOAssistant ProfessorDepartment of Physical Medicine and RehabilitationUniversity of Medicine and Dentistry of New JerseyNewark, New Jersey

Alberto Capa-Grasa, MD, PhDAttending PhysicianPhysical Medicine and RehabilitationUniversity Hospital La PazAttending PhysicianSports Medicine and Physical EducationUniversity Hospital La PazMadrid, Spain

Gary P. Chimes, MD, PhDAssistant ProfessorDepartment of Physical Medicine and RehabilitationUniversity of Pittsburgh Medical CenterFellowship Director, Musculoskeletal Sports & Spine FellowshipDivision Chief of Physical Medicine and Rehabilitation, UPMC-EastPittsburgh, Pennsylvania

John C. Cianca, MDClinical Associate ProfessorBaylor College of MedicineDepartment of Physical Medicine and RehabilitationPrivate PracticeBaylor College of MedicineHouston, Texas

Jackson Cohen, MDResidentDepartment of Rehabilitation MedicineUniversity of Miami School of MedicineMiami, Florida

Sean Colio, MDSports Medicine PhysiatristSwedish Spine, Sports, and Musculoskeletal MedicineSwedish Medical GroupSeattle, Washington

Paul A. Cook, MDPhysicianHand and Microsurgery Associates, Inc.Columbus, Ohio

Megan Helen Cortazzo, MDAssistant ProfessorVice Chair of Outpatient ServicesDepartment of Physical Medicine and RehabilitationUniversity of Pittsburgh School of MedicineUniversity of Pittsburgh Medical CenterPittsburgh, Pennsylvania

Jerod A. Cottrill, DOPrivate PracticeDepartment of Physical Medicine and RehabilitationRebound OrthopedicsPortland, Oregon

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xii ■ Contributors

Alfred C. Gellhorn, MDClinical Assistant ProfessorDepartment of Rehabilitation MedicineUniversity of WashingtonSeattle, Washington

Michael Goldin, MDFellowDepartment of Physical Medicine and RehabilitationUniversity of Medicine and Dentistry of New JerseyNewark, New Jersey

Bradly S. Goodman, MDAssociate ProfessorDepartment of Physical Medicine and RehabilitationUniversity of Alabama at BirminghamBirmingham, AlabamaAssociate ProfessorDepartment of Physical Medicine and RehabilitationUniversity of Missouri at ColumbiaColumbia, Missouri

Joshua G. Hackel, MD, FAAFPAssociate ProfessorFlorida State School of MedicineTallahassee, FloridaTeam PhysicianDepartment of AthleticsUniversity of West FloridaPensacola, Florida

Nelson A. Hager, MS, MDAssociate Clinical ProfessorDepartment of Physical Medicine and RehabilitationUniversity of Washington School of MedicineMedical DirectorBone and Joint, Sports and Spine CenterUniversity of Washington Medical CenterSeattle, Washington

Mederic M. Hall, MDAssistant ProfessorDepartment of Orthopaedics and RehabilitationUniversity of Iowa Sports Medicine CenterIowa City, Iowa

Jonathan S. Halperin, MDClinical AssociateDivision of PhysiatrySharp Rees Stealy Medical GroupSan Diego, California

Ronald W. Hanson Jr, MD, CAQSMFellowship Director, Interventional OrthopedicsCenter for Regenerative MedicineThe Centeno-Schultz ClinicBroomfield, Colorado

B. Elizabeth Delasobera, MDSports Medicine FellowDepartment of Family MedicineFairfax Family Practice - VCUFairfax, VirginiaAttending PhysicianDepartment of Emergency MedicineGeorgetown University HospitalWashington, District of Columbia

Rahul Naren Desai, MDSports and Pain InterventionalistMusculoskeletal RadiologyEPIC ImagingPortland, Oregon

Kevin deWeber, MD, FAAFP, FACSMAssistant ProfessorDepartment of Family MedicineUniformed Services University of the Health SciencesBethesda, MarylandDirector, Military Sports Medicine FellowshipDepartment of Family MedicineFt. Belvoir Community HospitalFt. Belvoir, Virginia

Kevin B. Dunn, MD, MSNew Jersey Sports Medicine, LLCCedar Knolls, New Jersey

John FitzGerald, MDAssociate Clinical ProfessorDavid Geffen School of MedicineDepartment of Medicine and RheumatologyUniversity of California Los AngelesLos Angeles, California

Michael Fredericson, MDProfessor and Attending PhysicianDepartment of Orthopaedic SurgeryStanford University, Hospital and ClinicsStanford, California

Bradley D. Fullerton, MDMedical DirectorPrivate Practice PhysiatristDepartment of Physical Medicine and Rehabilitation Specialty Care Center Pediatric Spasticity ClinicDell Children’s Medical Center of Central TexasAustin, Texas

Charles E. Garten II, MDPrivate PracticeSports MedicineMyers Sports Medicine and Orthopaedic CenterAtlanta, Georgia

Ched Garten, MDMyers Sports Medicine and Orthopaedic CenterAtlanta, Georgia

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Contributors ■ xiii

Keith Hardy, MDClinical InstructorDepartment of Rehabilitation MedicineUniversity of WashingtonSeattle, Washington

Kimberly G. Harmon, MDClinical ProfessorFamily Medicine and Orthopaedics and Sports MedicineUniversity of WashingtonTeam PhysicianUniversity of WashingtonSeattle, Washington

Eric Robert Helm, MDResidentDepartment of Physical Medicine and RehabilitationUniversity of Pittsburgh School of MedicinePittsburgh, Pennsylvania

Troy Henning, DOAssistant Professor and Attending PhysicianDepartment of Physical Medicine and RehabilitationUniversity of MichiganAnn Arbor, Michigan

John C. Hill, DO, FACSM, FAAFPProfessorDirector of Primary Care Sports Medicine FellowshipDepartment of Family MedicineUniversity of Colorado School of MedicineDenver, Colorado

Garry Wai Keung Ho, MD, CAQSMAssistant Program DirectorSports MedicineVCU-Fairfax Family Practice and Sports MedicineFairfax, VirginiaAssistant ProfessorFamily MedicineVirginia Commonwealth University School of MedicineRichmond, Virginia

Anne Z. Hoch, DOProfessorDepartment of Orthopaedic SurgeryMedical College of WisconsinMilwaukee, Wisconsin

Thomas M. Howard, MD, FACSMAssistant Clinical ProfessorDepartment of Family MedicineVCU School of MedicineRichmond, Virginia

Mandy Huggins, MDStaff PhysicianDepartment of OrthopaedicsBroward Health Physician GroupFt. Lauderdale, Florida

Mark-Friedrich Berthold Hurdle, MDAssistant ProfessorDepartment of Physical Medicine and RehabilitationMayo Clinic College of MedicineJacksonville, Florida

Garrett S. Hyman, MD, MPHClinical Assistant ProfessorDepartment of Rehabilitation MedicineUniversity of WashingtonSeattle, WashingtonConsulting PhysicianNorthwest Spine and Sports Physicians, PCKirkland, Washington

Victor Ibrahim, MDAssistant ProfessorDepartment of Rehabilitation MedicineGeorgetown University School of MedicineDirector, Ultrasound and Regenerative MedicineNational Rehabilitation HospitalWashington, District of Columbia

Jon A. Jacobson, MDProfessorDirector, Division of Musculoskeletal RadiologyDepartment of RadiologyUniversity of MichiganAnn Arbor, Michigan

Prathap Jayaram, MDResidentDepartment of Physical Medicine and RehabilitationBaylor College of Medicine/University of Houston AllianceHouston, Texas

Mark Edward Lavallee, MD, CSCS, FACSMAssociate Clinical ProfessorDepartment of Family MedicineIndiana University School of MedicineCo-DirectorSouth Bend-Notre Dame Sports Medicine Fellowship ProgramMemorial HospitalSouth Bend, Indiana

Matthew Leiszler, MDFellowPrimary Care Sports MedicineUniversity of ColoradoDenver, Colorado

Paul H. Lento, MDAssociate ProfessorDepartment of Physical Medicine and RehabilitationTemple University School of MedicineAttending PhysicianDepartment of Physical Medicine and RehabilitationTemple University HospitalPhiladelphia, Pennsylvania

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xiv ■ Contributors

John M. Lesher, MD, MPHAdjunct Assistant ProfessorDepartment of Physical Medicine and RehabilitationUniversity of North CarolinaChapel Hill, North CarolinaAttending PhysicianDepartment of Physical Medicine and RehabilitationCarolina Neurosurgery and Spine AssociatesCharlotte, North Carolina

John L. Lin, MDAssistant ProfessorDepartment of RehabilitationEmory UniversityDirector of Post Acute Spinal Cord ServicesShepherd CenterAtlanta, Georgia

Arthur Jason De Luigi, DO, FAAPMR, DAPMAssistant ProfessorDepartment of Rehabilitation MedicineGeorgetown University School of MedicineDirector, Sports MedicineDepartment of Rehabilitation MedicineNational Rehabilitation Hospital/Georgetown University HospitalWashington, District of Columbia

Gerard A. Malanga, MDClinical ProfessorDepartment of Physical Medicine and RehabilitationUMDNJ—New Jersey Medical SchoolNewark, New JerseyFounding PartnerNew Jersey Sports Medicine, LLCSummit, New Jersey

Jennifer K. Malcolm, DOSports Medicine FellowSports Medicine InstituteSaint Joseph Regional Medical CenterMishawaka, IndianaMark Lavallee, MarylandDepartment of Sports MedicineMemorial HospitalSouth Bend, Indiana

Srinivas Mallempati, MDAttending PhysicianDepartment of Physical Medicine and RehabilitationSt. Vincents EastAttending PhysicianDepartment of Physical Medicine and RehabilitationTrinity Medical CenterBirmingham, Alabama

Sean N. Martin, DOFacultyFamily Medicine ResidencyHQ Air Armament CenterEglin Air Force Base, FloridaSports Medicine Physician

Javier Vaquero Martín, MD, PhDProfessorDepartment of Orthopaedic SurgeryUniversity of Gregorio MarañónMadrid, Spain

R. Amadeus Mason, MDAssistant ProfessorDepartment of OrthopaedicsEmory University School of MedicineAtlanta, Georgia

Kenneth R. Mautner, MDAssistant ProfessorDepartment of OrthopaedicsPhysical Medicine and RehabilitationEmory HealthcareAtlanta, Georgia

Matthew D. Maxwell, MDDepartment of Physical Medicine and RehabilitationUniversity of Pittsburgh Medical CenterPittsburgh, Pennsylvania

John M. McShane, MDMcShane Sports MedicineVillanova, Pennsylvania

Brandon J. Messerli, DOEvergreen Sport and Spine CenterDepartment of PhysiatryEvergreen Health Kirkland, Washington

Johan Michaud, MD, FRCPCAssociate Professor of PhysiatryCentre Hospitalier de l’Université de MontréalUltrasound ConsultantInstitut De Physiatrie du QuébecMontreal, QuébecCanada

Megan Groh Miller, MDDepartment of Primary Care Sports MedicineUMDNJ-Robert Wood JohnsonNew Brunswick, New Jersey

Robert Monaco, MDDirector of Sports MedicineDepartment of AthleticsRutgers UniversityPiscataway, New JerseyClinical Assistant ProfessorDepartment of Family MedicineUMDNJ-Robert Wood Johnson Medical SchoolNew Brunswick, New Jersey

Sean W. Mulvaney, MDAssistant ProfessorDepartment of Emergency and Military MedicineUniformed Services UniversityBethesda, Maryland

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Contributors ■ xv

Rebecca Ann Myers, MDSports Medicine FellowSports MedicineUniversity of Notre DameSouth Bend, Indiana

Megan L. Noon, MDAssistant ProfessorDepartment of Orthopaedic Surgery, Physical Medicine

and RehabilitationMedical College of WisconsinMilwaukee, Wisconsin

Kambiz Nooryani, MDDepartment of Physical Medicine and RehabilitationNew Jersey Medical SchoolNewark, New Jersey

Prasanth Nuthakki, MDFellowInterventional PhysiatryAlabama Orthopedic Spine and Sports Medicine AssociatesBirmingham, Alabama

Jeffrey M. Payne, MDMayo Clinic Health SystemFaribault, Minnesota

Evan Peck, MDAssociate StaffSection of Sports MedicineDepartment of Orthopaedic SurgeryCleveland Clinic, FloridaWest Palm Beach and Weston, FloridaAffiliate Assistant ProfessorCharles E. Schmidt College of Medicine, Florida Atlantic UniversityBoca Raton, Florida

Scott Jeffery Primack, DO, FAAPMR, FACOPMRSenior Clinical InstructorDepartment of Physical Medicine and RehabilitationSchool of Public Health, University of Colorado School of HealthAurora, Colorado

Guillermo Emilio Rodríguez-Maruri, MDResidentDepartment of Physical Medicine and RehabilitationGregorio Marañón HospitalMadrid, Spain

Eugene Yousik Roh, MDClinical Assistant ProfessorDepartment of Orthopedics, Physical Medicine and RehabilitationStanford University Medical CenterRedwood City, California

Jose Manuel Rojo Manaute, MD, PhDDr. Prof. Javier Vaquero MartínDepartment of Orthopaedic SurgeryUniversity Hospital Gregorio MarañónMadrid, Spain

Joseph J. Ruane, DOAssociate Clinical ProfessorSports MedicineOhio University College of Osteopathic MedicineAthens, OhioMedical DirectorSpine, Sport & Joint CenterRiverside Methodist HospitalColumbus, Ohio

Gregory R. Saboeiro, MDAssociate ProfessorDepartment of RadiologyWeill Cornell Medical CenterAttending PhysicianDepartment of RadiologyHospital for Special SurgeryNew York, New York

Steven Sampson, DOClinical InstructorMedicineDavid Geffen School of Medicine at UCLALos Angeles, CaliforniaClinical Assistant ProfessorDepartment of Physical Medicine and RehabilitationWestern University of Health SciencesPomona, California

Jacob L. Sellon, MDSports Medicine FellowSports Medicine CenterDepartment of Physical Medicine and RehabilitationMayo ClinicRochester, Minnesota

Asal Sepassi, MDExternDepartment of Physical Medicine and RehabilitationUniversity of Medicine and DentistryNewark, New Jersey

Brian J. Shiple, DOAssistant Clinical ProfessorDepartment of Family MedicineTemple University School of MedicinePhiladelphia, Pennsylvania

Jevon SimerlyRestorePDXPortland, Oregon

Jay Smith, MDProfessorDepartment of Physical Medicine and RehabilitationMayo ClinicConsultantDepartments of Physical Medicine and Rehabilitation and RadiologyMayo ClinicRochester, Minnesota

Mala_FM_i-xxii.indd xvMala_FM_i-xxii.indd xv 08/11/13 1:58 PM08/11/13 1:58 PM

xvi ■ Contributors

Matthew Thomas Smith, MDSpine Health InstituteAltamonte, Florida

Joanne Borg Stein, MDAssociate ProfessorDepartment of Physical Medicine and RehabilitationHarvard Medical SchoolBoston, Massachusetts

Henry A. Stiene, MD, FACSMTeam PhysicianDepartment of Family MedicineBeacon Orthopaedics and Sports Medicine Xavier UniversityCincinnati, Ohio

Todd P. Stitik, MDProfessorDepartment of Physical Medicine and RehabilitationNew Jersey Medical SchoolDirector, Occupational/Musculoskeletal MedicinePhysical Medicine and RehabilitationNew Jersey Medical SchoolNewark, New Jersey

Jeffrey A. Strakowski, MDClinical Associate ProfessorDepartment of Physical Medicine and RehabilitationThe Ohio State University School of MedicineAssociate Director of Medical EducationDepartment of Physical Medicine and RehabilitationRiverside Methodist HospitalColumbus, Ohio

Kate E. Temme, MDClinical InstructorDepartment of Orthopaedic SurgeryMedical College of WisconsinMilwaukee, Wisconsin

Jose A. Ramirez-Del Toro, MDClinical InstructorDepartment of Physical Medicine and RehabilitationUniversity of Pittsburgh Medical Center (UPMC)Director of Sports MedicineCalifornia University of PennsylvaniaDirector of Sports Medicine and Spine CareThe Orthopedic Group, PCPittsburgh, Pennsylvania

Paul D. Tortland, DO, FAOASMMedical DirectorValley Sports Physicians and Orthopedic MedicineAvon, ConnecticutAssistant Clinical ProfessorDepartment of MedicineUniversity of Connecticut School of MedicineFarmington, Connecticut

Ricardo J. Vasquez-Duarte, MDAssistant ProfessorDepartment of Physical Medicine and RehabilitationUniversity of Miami Miller School of MedicineMiami, Florida

Christopher J. Visco, MDAssistant ProfessorDepartment of Rehabilitation and Regenerative MedicineColumbia University College of Physicians and SurgeonsAssistant Attending PhysicianDepartment of Rehabilitation and Regenerative MedicineNew York Presbyterian HospitalNew York, New York

Brandee L. Waite, MDAssistant ProfessorAssociate Director Sports Medicine FellowshipDepartment of Physical Medicine and RehabilitationUniversity of California Davis School of MedicineSacramento, California

Nicholas H. Weber, DOResident PhysicianDepartment of Physical Medicine and RehabilitationUniversity of Pittsburgh Medical CenterPittsburgh, Pennsylvania

Adam D. Weglein, DO, DABMAAssistant Clinical ProfessorDepartment of Family MedicineUniversity of Texas Houston Medical SchoolHouston, Texas

Beth M. Weinman, DOResident PhysicianDepartment of OrthopaedicsMedical College of WisconsinMilwaukee, Wisconsin

Steve J. Wisniewski, MDAssistant ProfessorDepartment of Physical Medicine and RehabilitationMayo ClinicRochester, Minnesota

Amy X. Yin, MDResident PhysicianDepartment of Physical Medicine and RehabilitationHarvard Medical School/Spaulding Rehabilitation HospitalBoston, Massachusetts

Mala_FM_i-xxii.indd xviMala_FM_i-xxii.indd xvi 08/11/13 1:58 PM08/11/13 1:58 PM

FOREWORD

This book is long overdue. Since I started using ultrasound

to inject hip joints in our sports medicine center in October

2003, the use of ultrasound to perform diagnostic and thera-

peutic interventional procedures has increased dramatically.

In 2003, ultrasound-guided musculoskeletal interventions

were primarily performed by radiologists, dedicated muscu-

loskeletal ultrasound (MSK US) courses emphasizing inter-

ventional procedures were sparse, and the peer-reviewed

literature contained perhaps a few dozen articles focusing on

interventional MSK US. Nearly a decade later, US-guided

musculoskeletal interventions are regularly performed by

not only radiologists but also physiatrists, family practitio-

ners, rheumatologists, anesthesiologists, orthopedic surgeons,

podiatrists, neurologists, and multiple other groups. Interven-

tional MSK US training has been integrated into many resi-

dency and fellowship training programs. Dedicated MSK US

courses are relatively easy to find, and many include specific

interventional training on cadavers. Finally, depending on the

journals you read (and my friends and colleagues know that

my list is long), there are one or more articles pertaining to

interventional MSK US published every month. Admittedly,

it is becoming increasingly difficult to keep up with the field.

Although I, like many others, have reflected upon these

past 10 years with both astonishment and a sense of accom-

plishment, I could not help but recognize that one important

task had not yet been completed. Every well-established field

has a reference text…a foundation…a “go to” resource. Yet,

no such text existed in the field of interventional MSK US.

Beginners in the field had no textbook from which to learn

the basics of interventional MSK US. More experienced

practitioners had no easily accessible reference to review

less frequently performed procedures or efficiently familiar-

ize themselves with new procedures. And finally, those who

might be considered “experts” in the field of interventional

MSK US by many had no place to share the wisdom they had

gained through years of experience (and many mishaps). Con-

sequently, I am extremely pleased that Drs. Gerry Malanga

and Kenneth Mautner decided to produce this multi-authored

textbook in which the “state of the art” of interventional MSK

US is presented.

Atlas of Ultrasound-guided Musculoskeletal Injections

provides a comprehensive overview of interventional MSK

US presented in a logical and user-friendly format. Whereas

the initial chapters cover the fundamentals of interventional

MSK US, the main body of the text dedicates one chapter

to each US-guided procedure. The format of each chapter

has been standardized for learning efficiency and includes

sections on key points, pertinent anatomy, common pathol-

ogy, US imaging, indications, and technique. Perhaps most

impressive is the vast spectrum of procedures covered in the

text, which ranges from basic US-guided joint injections to

perineural injections, tenotomies, and surgical procedures

such as percutaneous A1 pulley release. Consequently, this

text will appeal to practitioners from diverse backgrounds and

skill levels.

Of particular importance to me is that this text is authored

by experienced practitioners from multiple disciplines. In my

opinion the dramatic advances of the past decade have been a

direct result of the collaboration between enthusiastic practi-

tioners from multiple disciplines who shared a common goal

of improving patient care. Thus, Atlas of Ultrasound-guided

Musculoskeletal Injections appropriately provides a written

record of the field of interventional MSK US as told by many

of those who actively participated in its development. Thanks

to Gerry, Ken, and the multidisciplinary group of authors

who have dedicated their expertise, time, and effort to fill an

important gap in the field of interventional MSK US. In many

ways, the publication of this textbook was necessary to pro-

vide a foundation from which we can move into the future and

explore new methods to utilize US-guided interventions to

improve patient care. As I said, this textbook is long overdue.

Jay Smith, MD

Mayo Clinic

Rochester, Minnesota

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PREFACE

The use of diagnostic and interventional musculoskeletal

ultrasound has greatly enhanced our abilities in the diag-

nosis and treatment of a variety of musculoskeletal con-

ditions. Through our years of performing and teaching

ultrasound-guided injections, it became apparent that there

was no textbook to assist clinicians on how to properly

perform various ultrasound-guided injections. The medical

literature has increasingly demonstrated the superiority in

accuracy of ultrasound-guided injections when compared

to palpation-guided (“blind”) injections. Many clinicians

have experienced increased treatment options that can now

be offered to patients through the use of ultrasound-guided

injections.

As we write this book, the field of orthopedic medicine and

the way we practice are facing a paradigm shift. For years,

physicians of various specialties have used corticosteroid

injections as a mainstay of treatment for issues from tendini-

tis to arthritis. We have done this with limited proof of their

efficacy and significant evidence of the negative effects of

corticosteroids on tendons and chondral cartilage that may

result from this treatment. Over the past 5 years, orthobiolog-

ics treatments (i.e., the use of endogenous substances such as

platelet-rich plasma and bone marrow stem cells) have been

increasingly used and studied in treating soft tissue and car-

tilage disorders. The evidence for these treatments continues

to evolve. In the next 10 years, it is likely that the old para-

digm of treating supposed inflammation with steroid injec-

tions will continue to be replaced by using agents that will

promote tissue repair and modulation (inhibition) of degen-

erative inflammatory mediators. Many minimally invasive

techniques are being developed to deliver these orthobiolog-

ics, and ultrasound guidance is the predominate modality for

delivering these injections to the target tissue.

The focus of this textbook is to describe the techniques for

performing ultrasound-guided procedures without an empha-

sis on what is to be injected. Our goal is that each chapter

could be read independently describing the equipment for

the procedure, setup of the US machine, and approach to the

target area for each specific procedure. As an atlas, we hope

to cover almost every injection: joint, tendon, ligament, and

major nerves of the body that one may encounter in clini-

cal practice. We have also included some cutting-edge proce-

dures, such as ultrasound-guided carpal tunnel release, which

will likely expand in the years to come.

This book was a major collaborative effort among clini-

cians of various specialties who are considered to be leaders

in the field of musculoskeletal ultrasound. We selected chap-

ter authors based on current practice experience, as many of

these injections have never been described in the literature

and hence there are no studies to compare techniques. For

these chapters we have tried to provide the most efficient

way to reach the target tissue. We hope that this book will

challenge the readers, should they not agree with us, to set

up comparative studies that may further evaluate the effec-

tiveness of these procedures. Such studies are already being

carried out in various centers around the world. We hope

that the readers of this Atlas find it helpful in optimizing

the treatments that they offer to their patients providing a

state-of-the-art approach to the use of ultrasound guidance.

We look forward to your feedback to enhance this Atlas in

the future.

We would like to thank the multiple chapter authors for

their diligence in producing high-quality chapters. Special

thanks to Brian Belval who initially approached us regard-

ing the concept of this textbook. Many, many thanks to Sarah

M. Granlund, the Project Manager of this textbook. It is only

through her efforts in working with us as well as all the chap-

ter authors that this textbook has become a reality.

Sincerely,

Gerard A. Malanga, MD

Kenneth R. Mautner, MD

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ACKNOWLEDGMENTS

We would like to thank all the authors who contributed to this

book and all those who have advanced the field of Musculo-

skeletal Ultrasound over the past decade. We especially want

to acknowledge Keith Hardy, a friend and contributor to this

textbook, who recently passed away. Most importantly, none

of this could be possible without the loving support of our

wives and children.

Gerard A. Malanga, MD

Kenneth R. Mautner, MD

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33

KEY POINTS

CHAPTER 7

Evan Peck, MD

Sternoclavicular Joint Injection

■ Use a high-frequency linear array transducer.

■ Use a small-gauge (eg, 25) and relatively short (eg,

1.5-inch) needle.

■ Use caution to avoid passing the needle posterior to the

joint, where it may injure vital structures.

Pertinent Anatomy

The sternoclavicular joint (SCJ) is a diarthrodial joint con-

sisting of the articulation between the manubrium sterni, the

proximal clavicle, and the cartilage of the first rib (Figure 7-1).

The SCJ is stabilized by three major ligaments: the sternocla-

vicular ligament (consisting of the anterior, posterior, superior,

and inferior sternoclavicular ligaments), which attaches the

manubrium sterni to the clavicle; the costoclavicular ligament,

which attaches the cartilage of the first rib to the clavicle; and

the interclavicular ligament, which attaches the proximal end

of one clavicle to that of the other, and also attaches to the supe-

rior manubrium sterni. The joint contains an intraarticular disk.

Several vital structures are situated directly posterior to the

SCJ, including the subclavian vessels, trachea, and esophagus.

Common Pathology

The SCJ may be injured by a direct impact to the joint, or

indirectly from a blow to the shoulder. SCJ injuries may

be classified into sprains, partial ligamentous tears, and

FIGURE 7-1 ■ The sternoclavicular joint.

Sternal endof clavicle

Articular disc

Anterior sterno-clavicular ligament

Costo-clavicularor rhomeoidligament

Cartilage of1st rib

Inter-clavicularligament

Manubriumof sternum

complete ligamentous tears with resultant subluxations

and dislocations. Subluxations and dislocations of the SCJ

may be anterior or posterior. Posterior dislocations are of

increased concern because of the vital structures that exist

directly posterior to the joint. Osteoarthritis may also affect

the SCJ.

Ultrasound Imaging Findings

The SCJ is best sonographically visualized in its long axis, per-

pendicular to the joint line, using a high-frequency linear array

transducer, generally with a top frequency of no less than 10

MHz. The joint is typically easily located by direct palpation

prior to transducer placement. The intraarticular disk may be

visualized as a hypoechoic structure within the joint; increas-

ing the ultrasound’s gain setting may accentuate its appearance.

Pathology that may be visualized sonographically includes

cortical irregularities, widening or instability of the joint

(examined statically or dynamically), and joint effusion with

capsular distension.

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34 ■ Chapter 7 / Sternoclavicular Joint Injection

Indications for Sternoclavicular Joint Injection

Injection of the SCJ may be considered for patients with recal-

citrant pain resulting from an SCJ-associated pain generator

that is unresponsive to appropriate activity modifications, oral

or topical medications, therapeutic modalities, therapeutic

exercises, and protection or bracing where indicated. In addi-

tion, SCJ injection may be used for diagnostic purposes if the

primary pain generator is uncertain based on history, physical

examination, and imaging findings.

Palpation-guided SCJ injection has been described, with

accuracy documented to be 78% in one study.1 Neither the

accuracy of ultrasound-guided SCJ injections, nor a com-

parison of clinical outcomes between palpation-guided and

ultrasound-guided SCJ injections, have been reported in the

literature.

Equipment

■ Needle: 25-gauge, 1.5-inch

■ Injectate: 0.5–1 mL of local anesthetic and 0.5–1 mL of

corticosteroid

■ Ultrasound machine with high-frequency linear-array

transducer

Author’s Preferred Technique

a. Patient position

i. Seated or supine

ii. Arm adducted in neutral rotation

b. Transducer position (Figure 7-2)

i. Anatomic sagittal oblique plane over the anterior

aspect of the SCJ

c. Needle orientation relative to the transducer (see

Figure 7-2)

i. In plane

d. Needle approach (Figure 7-3)

i. Anterior to posterior

e. Target

i. Anterior SCJ

f. Pearls/Pitfalls

i. Caution should be taken to avoid advancement of

the needle beyond the SCJ, where it may injure vital

structures.

FIGURE 7-2 ■ Transducer position and needle orientation for an anterior approach, transducer short-axis to joint, needle in-plane ul-trasound-guided SCJ injection. Sterile transducer cover not pictured.

FIGURE 7-3 ■ Ultrasound image for an anterior approach, trans-ducer short axis to joint, needle in-plane ultrasound-guided SCJ in-jection. Arrow corresponds to needle position during injection. Left, posterior; top, superficial. Note there are no bony landmarks for this injection approach.

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Chapter 7 / Sternoclavicular Joint Injection ■ 35

Reference1. Weinberg AM, Pichler W, Grechenig S, et al. Frequency of suc-

cessful intra-articular puncture of the sternoclavicular joint: a cadaver study. Scand J Rheumatol. 2009;38(5):396–398.

Alternate Technique

a. Patient position

i. Seated or supine

ii. Arm adducted in neutral rotation

b. Transducer position (Figure 7-4)

i. Anatomic coronal oblique plane over the medial

aspect of the SCJ

c. Needle orientation relative to the transducer (see

Figure 7-4)

i. In plane

d. Needle approach (Figure 7-5)

i. Medial to lateral

e. Target

i. Medial SCJ

f. Pearls/Pitfalls

i. Caution should be taken to avoid advancement of

the needle beyond the SCJ, where it may injure vital

structures.

ii. An oblique stand-off technique may be necessary,

wherein additional sterile ultrasound gel is placed on

the patient’s skin over the SCJ and the manubrium

sterni, in order to maintain continuous visualization

of the needle while using this injection approach.

This is particularly true if a large step-off deformity

exists from SCJ injury.

FIGURE 7-5 ■ Ultrasound image for a medial approach, transducer long axis to joint, needle in-plane ultrasound-guided SCJ injection. Arrow corresponds to needle position during injection. Note oblique stand-off technique, with additional ultrasound gel stacked medially. This is visible in the upper right corner of the image. Left, lateral; top, superficial; C, clavicle; S, sternum.

FIGURE 7-4 ■ Transducer position and needle orientation for a medial approach, transducer long-axis to joint, needle in-plane ul-trasound-guided SCJ injection. Sterile transducer cover not pictured.

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KEY POINTS

141

Sean N. Martin, DO

CHAPTER 35Third Dorsal Compartment of the Wrist Injection

Pertinent Anatomy

Located just ulnar (medial) to Lister’s tubercle, the third dor-

sal compartment of the wrist contains the extensor pollicis

longus (EPL) exclusively (Figure 35-1A and B). This tendon

contributes extension of the thumb and is accentuated during

sonography by actively resisting the patient while he or she

performs this motion.

Common Pathology

Pathology of the EPL tendon is often that of localized teno-

synovitis. This is most prominent as the thin tendon courses

next to Lister’s tubercle. Often, fluid is seen within the ten-

don sheath just proximal to the tubercle. Patients typically

describe pain localized to this location and, potentially, crepi-

tus with movement of their thumb. Less commonly, the EPL

tendon can become irritated immediately after its intersection

with the extensor carpi radialis longus tendon.1 Isolated par-

tial tears of the EPL tendon, either related to or independent

from tenosynovitis, can be seen on ultrasound imaging. One

predisposing factor to a tear is a previous distal radius fracture

adjacent to a particularly thin portion of the tendon. 1 It should

be noted, as well, that complete EPL rupture is a known com-

plication of distal radius fractures. Presence of rheumatoid

arthritis and use of corticosteroids (both locally and systemi-

cally) are also known risk factors for tendon rupture.2

■ Use a 23- to 25-gauge, 1.5-inch needle, distal to proxi-

mal, in plane.

■ Use a high-frequency linear array transducer.

■ Lister’s tubercle should serve as major landmark for

identifying this compartment.

■ Extensor pollicis longus tendon rupture is a known com-

plication following corticosteroid injection.

FIGURE 35-1 ■ A. Anatomy of the dorsal compartments of the wrist. B. Short axis view of the dorsal wrist. 3 EPL, extensor pol-licis longus.

65 4 2

1

3

A

635 4

2

1B

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142 ■ Chapter 35 / Third Dorsal Compartment of the Wrist Injection

FIGURE 35-3 ■ Transverse view of EPL tendon with “hockey stick” probe. Arrow represents needle entry from radial to ulnar, in plane. 2nd, second dorsal compartment; 3rd, third dorsal compart-ment; 4th, fourth dorsal compartment; LT, Lister’s tubercle.

c. Needle orientation relative to the transducer (Figures 35-2

and 35-3)

i. In plane

d. Needle approach (see Figure 35-3)

i. Ulnar to radial or radial to ulnar

e. Target (see Figure 35-3)

i. Space between tendon sheath and tendon

f. Pearls and Pitfalls

i. Be sure to scan the area prior to injecting and use

power Doppler to avoid any nerves or vessels in the

area.

ii. Active patients should be counseled on reports of

rupture of the EPL tendon following corticosteroid

injection.3

Ultrasound Imaging Findings

The third compartment is most easily visualized in long and

short axis using a high-frequency linear array transducer at a

depth of less than 2 cm. Often it is helpful to float the trans-

ducer using a thick layer of ultrasound gel. This compart-

ment is most easily identified by first locating the prominent

Lister’s tubercle, which separates the third (ulnar aspect of

the tubercle) and second compartments (radial aspect of the

tubercle). This tubercle is seen as a hyperechoic prominence

of the dorsal radius. Correct identification of the EPL is most

reliably accomplished by visualization of the tendon at this

location as the tendon crosses the tendons of the second dor-

sal compartment (extensor carpi radialis longus and extensor

carpi radialis brevis) as it courses distally. The tendon is most

easily tracked using a short-axis view while remembering that

the tendon courses obliquely from medial to lateral. Imprecise

scanning through anisotropy may provide the false appear-

ance of a pathologic tendon, so it is imperative to not scan this

tendon obliquely. Distally, the EPL tendon becomes closely

approximated to the tendon of the extensor pollicis brevis just

prior to its insertion on the distal phalanx of the thumb.

Indications for Injections of the Third Dorsal Compartment

Ultrasound-guided corticosteroid injection of the third dorsal

compartment is typically reserved for localized tenosynovitis

that is unresponsive to more conservative measures. At the

time of publication, there is a void of studies on the efficacy

of this procedure through either palpation- or ultrasound-

guided technique.

Equipment

■ Needle: 23- to 25-gauge, 1.5-inch needle

■ Injectate: 0.5 mL of local anesthetic and 0.5 mL of an

injectable corticosteroid

■ High-frequency linear array transducer

Author’s Preferred Injection Technique

a. Patient position (Figure 35-2)

i. Seated with hand resting prone on a flat surface

b. Transducer position (see Figure 35-2)

i. Short axis to EPL tendon

FIGURE 35-2 ■ High-frequency linear array transducer is trans-verse to the compartment and needle approach is in plane.

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Chapter 35 / Third Dorsal Compartment of the Wrist Injection ■ 143

3. Mills SP, Charalambous CP, Hayton MJ. Bilateral rupture of the extensor pollicis longus tendon in a professional goalkeeper following steroid injections for extensor tenosynovitis. Hand Surg. 1009;14(2-3):135–137.

Alternate Technique

a. Patient position (Figure 35-4)

i. Seated with hand resting prone on a flat surface

b. Transducer position (see Figure 35-4)

i. Long axis over EPL tendon

c. Needle orientation relative to the transducer (Figures 35-4

and 35-5)

i. In plane

d. Needle approach (see Figure 35-5)

i. Distal to proximal

e. Target (see Figure 35-5)

i. Space between tendon sheath and tendon

f. Pearls and Pitfalls

i. Short-axis scanning should also be used to confirm

both orientation of the needle toward the desired ten-

don and placement of the needle between the sheath

and the tendon.

ii. Active patients should be counseled on reports of

rupture of the EPL tendon following corticosteroid

injection.3

FIGURE 35-4 ■ High-frequency linear array transducer longitudi-nal to compartment; needle approach is in plane.

FIGURE 35-5 ■ Long-axis view of extensor pollicis longus (EPL) tendon with “hockey stick” probe. Arrow represents needle entry into tendon sheath from distal to proximal. 3rd, third dorsal com-partment.

References1. Bianchi S, Martinoli C. Ultrasound of the Musculoskeletal

System. New York: Springer; 2007.2. Björkman A, Jörgsholm P. Rupture of the extensor pollicis lon-

gus tendon: a study of aetiological factors. Scand J Plast Recon-str Surg Hand Surg. 2004;38(1):32–35.

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KEY POINTS

303

Pes Anserine Bursa Injection CHAPTER 74

Jacob L. Sellon, MD / Jay Smith, MD

■ High-frequency linear array transducers can be used to

image and inject the bursa.

■ The transducer can be oriented short or long axis relative

to the pes anserine tendons.

■ The pes anserine bursa is located between the medial col-

lateral ligament and the pes anserine conjoint tendon.

■ Tilting the transducer will increase pes anserine tendon

conspicuity by creating anisotropy.

■ Avoid nearby neurovascular structures (eg, inferior

medial geniculate artery).

Pertinent Anatomy (Figure 74-1)

The pes anserinus is a tendinous confluence formed by the

sartorius, gracilis, and semitendinosus tendons as they insert

at a common point on the proximal anteromedial tibia. The

pes anserine bursa lies in the potential space between these

conjoint tendons and the underlying medial collateral liga-

ment (MCL) and medial tibia.

Common Pathology

Pes anserinus pain usually results from bursitis or tendinitis

and may be caused by repetitive overuse or direct trauma.

Pain in this region has been associated with knee osteoarthri-

tis, rheumatoid arthritis, diabetes mellitus, and obesity.1 The

diagnosis is usually based on clinical findings. Symptoms

may be triggered by ambulation, and in particular, rising from

a seated position or climbing stairs. The key finding on physi-

cal examination is tenderness in the region of the pes anseri-

nus. Swelling in this area may also be present.

Pes anserinebursa

FIGURE 74-1 ■ Anatomy of the pes anserine bursa.

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304 ■ Chapter 74 / Pes Anserine Bursa Injection

Ultrasound Imaging Findings

The pes anserine tendons and bursa are usually best visual-

ized using a high-frequency linear array transducer. However,

a lower frequency probe may be preferable for patients with

large or edematous legs. The pes anserinus can be scanned

in both short (Figure 74-2) and long axes (Figure 74-3) rela-

tive to the tendons. Tilting the transducer to introduce tendon

anisotropy may increase the conspicuity of the pes anserine

tendons and facilitate differentiation of the tendons from the

underlying MCL (Figure 74-4). Although the sonographic

appearance of the pes anserine region is often normal in

patients presenting with clinical pes anserine tendinitis or bur-

sitis, one may occasionally visualize bursal fluid and/or ten-

don hypoechogenicity, either of which may be accompanied

by increased Doppler flow. The inferior medial geniculate

artery lies deep to the MCL and should not be misinterpreted

as bursal fluid or hypervascularity.

Indications for Pes Anserine Bursa Injection

Injection of the pes anserine bursa may be considered for

patients with recalcitrant pain unresponsive to rest, icing,

nonsteroidal antiinflammatory drugs, and physical therapy.

Using a cadaveric model, Finnoff and colleagues documented

a diagnostic accuracy rate (ie, injectate only located in bursa)

of 92% following sonographically guided pes anserine bursa

injections, compared to a 17% accuracy using a palpation-

guided technique. In comparison, the therapeutic accuracy

rates (ie, at least some injectate in the bursa) were 100% and

50%, respectively.2 Regarding clinical efficacy, Yoon and col-

leagues reported that ultrasound-guided pes anserine bursa

injections improved knee pain and function in patients with

knee osteoarthritis and concomitant pes anserine tendinitis/

bursitis.3 However, to date, no studies have directly compared

clinical outcomes of ultrasound-guided versus unguided

injections.

Equipment

■ Needle: 25-gauge, 1.5-inch needle

• Injectate

• 1–2 cc 1% lidocaine

• 1 cc corticosteroid

■ High-frequency linear array transducer

FIGURE 74-2 ■ Short-axis ultrasound image of pes anserine ten-dons (downward arrows) crossing superficial to the medial collateral ligament (MCL with diagonal arrow). The pes anserine bursa lies in the potential space between the pes anserine tendons and the MCL. Left, proximal; right, distal; top, superficial; bottom, deep.

FIGURE 74-3 ■ Long-axis ultrasound image of the gracilis tendon (downward arrow) crossing the underlying medial collateral liga-ment. The tendon appears dark due to anisotropy. Left, proximal; right, distal; top, superficial; bottom, deep.

FIGURE 74-4 ■ Same ultrasound image as Figure 74-2 after tilting transducer. Pes anserine tendons (downward arrows) are now aniso-tropic, increasing conspicuity.

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Chapter 74 / Pes Anserine Bursa Injection ■ 305

Author’s Preferred Technique (Figures 74-5, 74-6, and 74-7)

a. Patient position

i. Supine

ii. Hip externally rotated and knee slightly flexed

(rolled towel under knee)

b. Transducer position

i. Anatomic coronal plane (same plane as the MCL)

over the anterior fibers of the MCL

ii. Pes anserine tendons should be seen in an oblique

short-axis view as they cross the MCL

c. Needle orientation relative to the transducer

i. In plane (long axis/longitudinal)

d. Needle approach

i. Distal (inferior) to proximal (superior)

e. Target

i. Deep to the pes anserine tendons (central tendon

if multiple tendons are seen) and superficial to the

MCL

ii. If fluid is seen within the bursa, this can be targeted

appropriately

f. Pearls and Pitfalls

i. Tilt the transducer to increase tendon conspicuity as

described above.

ii. The angle of needle approach is shallow unless pa-

tient’s leg is large.

iii. Avoid injecting into the pes anserine tendons or

MCL.

iv. Doppler may help identify vessels (inferior medial

geniculate artery, saphenous vein).

v. The branches of the saphenous nerve may be located

in this region.

FIGURE 74-5 ■ Setup for pes anserine bursa injection using short-axis view of the pes anserine tendons.

FIGURE 74-6 ■ Same ultrasound image as Figures 74-2 and 74-4, demonstrating needle advancing in plane, distal to proximal, into the region of the pes anserine bursa.

FIGURE 74-7 ■ Pes anserine “bursogram” following injection us-ing setup and approach shown in Figures 74-5 and 74-6.

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306 ■ Chapter 74 / Pes Anserine Bursa Injection

f. Pearls and Pitfalls

i. See “Pearls and Pitfalls” under “Author’s Preferred

Technique”

References1. Handy JR. Anserine bursitis: a brief review. South Med J

1997;90:376–377.2. Finnoff JT, Nutz DJ, Henning PT, Hollman JH, Smith J. Accu-

racy of ultrasound-guided versus unguided pes anserinus bursa injections. PM R 2010;2:732–739.

3. Yoon HS, Kim SE, Suh YR, Seo YI, Kim HA. Correlation between ultrasonographic findings and the response to cortico-steroid injection in pes anserinus tendinobursitis syndrome in knee osteoarthritis patients. J Korean Med Sci 2005;20:109–112.

Alternate Technique (Figures 74-8, 74-9, and 74-10)

a. Patient position

i. Supine

ii. Hip externally rotated and knee slightly flexed

(rolled towel under knee)

b. Transducer position

i. Start by finding the short-axis view of pes anserine

tendons as described above, and center gracilis ten-

don on the screen.

ii. Then rotate into long-axis view of central (graci-

lis) portion of conjoint tendon in anatomic coronal

oblique plane.

c. Needle orientation relative to the transducer

i. In plane (long axis/longitudinal)

d. Needle approach

i. Distal (inferior) to proximal (superior)

e. Target

i. Deep to the pes anserine tendons (central tendon

if multiple tendons are seen) and superficial to the

MCL.

ii. If fluid is seen within the bursa, this can be targeted

appropriately.

FIGURE 74-8 ■ Setup for pes anserine bursa injection using a long-axis view of the pes anserine tendons.

FIGURE 74-9 ■ Same ultrasound image as Figure 74-3, demon-strating needle advancing in plane, distal to proximal, into the region of the pes anserine bursa.

FIGURE 74-10 ■ Pes anserine “bursogram” following injection us-ing setup and approach shown in Figures 74-8 and 74-9.

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